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�`(" SAN JOAQUIN COUNTY CRIGIINAI.— ENVIRONMENTAL HEALTH DEPARTMENT '•'• '•/ 1868 Hazelton Avenue, Stockton, CA 95205-6232 �`r^`�`LJ� �`o •:r,;:•NcP` Telephone: (209) 468-3147 Fax.(209) 468-3433 Web:www.sigov.org/ehd. �/FOR WELL & BORING PERMIT APPLICATION APRA 4 2014 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH PERMIT/SERVICES Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 4 Site Location VAP--% b�,6 Cross Street&, �� t`"*��> City/Stat-'k'r*P � ,"Azip `.r � �l� APN {��5` 0 1 P i(9 Property r Owner �P~ —D--- Address( C'J `i}� ,>(yt,P;S y►('4`'sc. '1 City/State l,"'q ' Zip EDS tom+ Phone i C-57 Contractorj:E,F-',,G t P-Lu ,i Address q56 A-- City/StateP�=�'.it=t.,ALic `a Sri Phone �V,; i? - (�rd Consultant/Sub Cntr Address City/State Lic PPIS 10% Phone Billable Party Address City/State Zip Phone GIS Coordinates:X 372ZS 19Y -121 271,0 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Cl @,y c ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 'L IK EXTRACTION:Vap.<Ea1]ft ❑HAMMERIDRIVEN CASING THICKNESS d3• f-VC- TYPE OF CASING: 0 STEEL N PVC 0 OTHER _❑SOIL VAPOR PROBE 1 j MUD ROTARY DEPTH OF GROUT SEAL 56C F iC,''TREMIE TYPE TO BE USED: ❑AUGERS 0 HOSE 12 PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:®Yes O No(MAXIMUM FREE FALL DEPTH IS 30 FT) _O INJECTION(i.e.Air Snarae Ozone)❑HAND AUGER GROUT SPECIFICATIONS t S?<• Moe K 0 OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR V STOVE PIPE COMMENTS: CONDUCTOR CASING®No Yes:Ming Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all applicable California laws. / fGvU..�tS— Signed ,[�. --�-•----r�/ -..�./t—:K-•� Title/Company Print Name ✓r.�sf a .. J. . ;C r' Date q DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS �2 RO 4?01 j D I /-4 77Y ky ice_ WORK PLAN DATED P (1• y 2,af q APPLICATION ACCEPTED BY J-York"W\ DAT EZUREA /G49 GROUT INSPECTION BY FINAL INSPECTION BI � SATE J�y DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE pp u� REQUEST PR# -lU I $125 x 4. 7�2- �y SR# 6 RO# l (3500 PR# 2900 C-57 // WC V WAIVER IrAIA C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT d ENCROACHMENT DOC_,824_ EHD 29-01 5109/12 1 WELL PERMIT APP